CESPHN Clinical Services Initial Referral Form		

This is NOT A CRISIS Service
If crisis support is required, call 000 or the Mental Health Access Line on 1800 011 511.

Information provided will be used to assist selection of the service for the individual’s needs.
Referral Date:	<TodaysDate>

Eligibility Criteria for PSS Program - MANDATORY

All eligibility criteria must be met
Individual Income is less than $55,000 or family income is less than $130,000	<Individual Income is less than $55,000 or family income is less than $130,000?>	
Live, work or study in the Central and Eastern Sydney region	<Live, work or study in the Central and Eastern Sydney
region?> Find your local PHN	
If the individual's address is out of the CESPHN area, do they work or study in the CESPHN area?	<If the individuals address is out of the CESPHN area, do they work or study in the CESPHN area?>	
Mild to moderate mental illness	<Mild to moderate mental illness>	
The individual does NOT need a crisis or specialist DV service	<Does NOT need a crisis or specialist DV service>	
The individual does NOT need support with court or insurance matters <Does NOT need support with court or
insurance matters>	

This form can be billed as a Mental Health Treatment Plan if all components are filled in satisfactorily

GP MHTP - MBS items 2700, 2701, 2712, 2713, 2715 and 2717
Child referral - MBS Item: 36 (20+ mins) / MBS Item: 44 (40+ mins)
COVID-19 Telehealth MBS items: Telehealth MBS Items

GP Details	
GP name:	<UsrName>	Position:	<UsrQualifications>	
Practice name:	<LocationName>	Address:	<LocationAddress>	
Practice phone:	<LocationPhone>	Practice email:	<LocationEmail>	

Individual's Details	
First Name:	<PtFirstName>	Surname:	<PtSurname>	Preferred Name:	<PtPrefName>	
Date of Birth:	<PtDoB>	Gender:	<GenderIdentity>	Sexuality:	<PtSex>	

Country of birth:	

<Country of Birth>	
Aboriginal and/or Torres Strait Islander:	

<PtEthnicity>	Identifies as Culturally and Linguistically Diverse:	<Identifies as Culturally and Linguistically Diverse>	
English proficiency:	<English proficiency>	Preferred language:	<Preferred language>	Interpreter required?	<Interpreter>	
Homelessness Flag?	<Homelessness Flag?>	NDIS
Participant?	<NDIS
Participant?>	Health Care Card?	<Healthcare card?>	

Individual's Contact details	
Address:	<PtAddress>	
Phone 1:	<PtPhoneH>	Phone 2:	<PtPhoneMob>	
Email:	<PtEmail>	

Next of Kin	
MANDATORY for all referrals
This includes parent/carer details if the individual is a Child and/or emergency contacts
Next of Kin/Emergency Name:	<NOKName>	
Relationship	<NOKRelation>	
Phone	<NOKContact>	
Consent to	contact NOK/emergency	<NOK Consent to contact>	

Clinical Assessment

Symptom severity and distress
Consider the severity, duration, complexity, and distress resulting from the person's symptoms
A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000
<1. Symptom severity and distress - Consider the severity, duration, complexity, and distress resulting from the person's symptoms - A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000>

Risk of harm
Consider the level of risk as it relates to the person's potential for harm to self or others
A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000
<2. Risk of harm - Consider the level of risk as it relates to the person's potential for harm to self or others - A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000>

2a. Consider the level of risk as it relates to the person's potential for harm to self or others including domestic violence, aggression and forensic
<2a. Consider the level of risk as it relates to the person's potential for harm to self or others including domestic violence, aggression and forensic>

Functioning
Consider the person's ability to function in their daily duties and roles
<3. Functioning - Consider the person's ability to function in their daily duties and roles>

Impact of Co-existing Conditions
Are there co-existing conditions impacting on mental health or ability to participate in treatment?
<4. Impact of co-existing conditions>

4a. Type of co-existing conditions
<4a. Type of co-existing conditions>

Treatment and recovery history
Consider the person's previous treatment history, current service use and response to past or current treatment
<5. Treatment and recovery history - Consider the person's previous treatment history, current service use and response to past or current treatment>

Social and environmental stressors
Consider how the person's environment is contributing to their mental health condition
<6. Social and environmental stressors>

6a. Social and environmental stressors types;
Select one or more from the following types of stressors
<6a. Social and environmental stressor types>

Family and other supports
Consider the informal supports that are available and capable of contributing to recovery
<7. Family and other supports - Consider the informal supports that are available and capable of contributing to recovery>

7a. Please list the most useful supports available to the person
<7a. Please list the most useful supports available to the person>

Engagement and motivation	Consider if the person understands their mental health condition, capacity to manage their condition and their willingness/motivation to participate in treatment
<8. Engagement and motivation - Consider if the person understands their mental health condition, capacity to manage their condition and their willingness/motivation to participate in treatment>

PSS Referral	
Please select from the list of underserviced groups	<Please select from the list of underserviced groups>	
If Group Referral, enter the name of the PSS Group	<If Group Referral, enter the name of the PSS Group>	
For 'Young Person' selection, would a referral to headspace be appropriate for this patient?	<For 'Young Person, would a headspace referral be appropriate?>	
For 'Perinatal' selection, select the baby's due date or date of birth	<For 'Perinatal' selection, select the baby's due date or date of birth>	
Does the individual identify as transgender or gender diverse?	<Does the individual identify as transgender or gender diverse?>	

For 'Children' referral selection, please complete the below fields:

Does the child have any learning, social or behavioural issues?	<For 'Children' referral selection, does the child have any learning social or
behavioural issues?>	

Does the child have any eating, sleeping or exercise related concerns?	<For 'Children' referral selection, does the child have any eating, sleeping or exercise
related concerns?>	

Clinical and treatment history - MANDATORY	
Agreed date for MHTP review: 4 weeks to 6 months after initial MHTP	<Agreed date for MHTP review: 4 weeks to 6 months after initial MHTP>	
Diagnosis	<Initial Diagnosis>	
Additional diagnosis (if applicable)	<Additional Diagnosis (if applicable)>	
Please add further information on diagnosis if required	<Diagnosis - more information if applicable>	
Presenting Issues - What are the current mental health issues?
MANDATORY	<Presenting Issues - What are the current mental health issues? MANDATORY>	
Individual's Goal - What treatment is recommended and what is to be achieved by the treatment
MANDATORY	<Individual's Goal - What treatment is recommended and what is to be achieved by the treatment - MANDATORY>	
Have you discussed the assessment, referral and treatment options with the individual?	<Have you discussed the assessment, referral and treatment options?>	
Have you provided psychoeducation?	<Have you provided psychoeducation?>	
Current Services (please specify)	<Please specify current services>	
Previous Treatment	<Previous Treatment>	

Please specify previous treatment	<Please specify previous treatment>	
If yes is selected for previous CESPHN commissioned services used, please specify	<If yes is selected for previous CESPHN commissioned services used, please specify>	
Medications	<Medications>	
Any other relevant information?	<Any other relevant information?>	
Outcome tool used:	<Outcome tool completed><Please specify
Other outcome tool>	Outcome tool score:	<Outcome tool score>	

Crisis/Safety Relapse Plan	
Please provide an outline of the crisis/safety plan
MANDATORY	<Please provide an outline of the crisis/safety plan>	
Please provide details of any mental health related hospital admission in the last 12 months	<Please provide details of any mental health related hospital admission in the last 12 months>	

Mental State Examination	-	MANDATORY	
Appearance/ Behaviour	<Appearance/ Behaviour>	Mood	<Mood>	Affect	<Affect>	
Thinking	<Thinking>	Sleep	<Sleep>	Perception	<Perception>	
Appetite	<Appetite>	Anhedonia	<Anhedonia>	Motivation/ Energy	<Motivation/ Energy>	
Attention/ Concentration	<Attention/ Concentration>	Judgement/ Insight	<Judgement/ Insight>	Memory	<MSE Memory>	
Speech	<Speech>	Orientation	<Orientation>			

PSS Mental Health Practitioner Request

Would you like to nominate a specific PSS Mental Health Practitioner?
<Preferred Provider Name: (Please include any specific needs regarding travel, gender etc.)>
If not, a PSS Provider will be allocated based on location.

If preferred Mental Health Practitioner is not available, do you consent for an alternative provider to be allocated? <If preferred Mental Health Practitioner is not available, do you consent for an alternative provider to be allocated?>

Consent - MANDATORY

I understand referrals made to the non-acute Suicide Prevention Support (SPS) program will be allocated to a provider within 72 hours. (Referrals received after 12pm on Friday may not be allocated until the following Monday)
<I understand referrals made to the non-acute Suicide Prevention Support (SPS) program will be allocated to a provider within 72 hours. (Referrals received after 12pm on Friday may not be allocated till the following Monday)>
Referrers must confirm that they have read out the following and that the individual understands and has given (informed) verbal consent:
I consent to telehealth services and have access to a device that has a secure internet connection	<I consent to telehealth services and have access to a device that has a secure internet connection>
I have consented to participate in the program as it has been described to me by my referrer, and to being contacted by the allocated Mental Health Professional to arrange an appointment
<I have consented to participate in the program as it has been described to me by my referrer, and to being contacted by the allocated Mental Health Professional to arrange an appointment>

I have consented to my information being shared between the service provider and the funding body Central and Eastern Sydney PHN (CESPHN), in accordance with the Privacy Act 1988
<I have consented to my consented to their information being shared between the service provider and the funding body Central and Eastern Sydney PHN (CESPHN), in accordance with the Privacy Act 1988 >

I have consented to my de-identified information such as date of birth, gender, and types of service used, being shared with the Department of Health and Ministry of Health for mandatory reporting requirements
<I have consented to my de-identified information such as date of birth, gender, and types of service used, being shared with the Department of Health and Ministry of Health for mandatory reporting requirements>

I have consented to my de-identified information, including this referral form being shared with CESPHN for project evaluation and quality improvement purposes, and agrees to be offered an experience of service survey
<I have consented to my de-identified information, including this referral form being shared with CESPHN for project evaluation and quality improvement purposes, and agrees to be offered an experience of service survey>

GP Signature:		Date: <TodaysDate>

For more information on all Mental Health programs in the Central and Eastern Sydney region, visit www.cesphn.org.au